In This Issue
This issue of The Milbank Quarterly begins with a call for the reorientation of public health research. In “Where Is the Future in Public Health?” Hilary Graham argues that the logic and ethical values of public health are strongly oriented toward the future but that the methods of public health research are not. She illustrates by focusing on three “exemplary” research approaches. The first is risk-factor epidemiology, which she criticizes for its focus on individual risk factors rather than social and environmental variables. The second is the randomized controlled trial, which generally focuses on short-term outcomes, and the third is economic evaluation, in which effects on current populations are given more weight than discounted future populations are.
Graham’s point is that new research perspectives and practices will be needed if the field of public health research is to grapple with the health of future populations, because current practices and policies (for example, regarding the climate) will have major consequences in the future. Although this is a formidable challenge, she offers some thoughts about possible strategies, including some that are already being followed in fields such as life course analysis (Halfon and Hochstein 2002). Quoting Funtowicz and Ravetz (1993), Graham argues that when “facts are uncertain, values in dispute, stakes high and decisions urgent,” a new scientific paradigm—which Funtowicz and Ravetz term “post-normal science”— is needed, in which uncertainty is a reason to act, not justification for delay.
The transformation of a research field is also the agenda of the second article in this issue. Even though researchers from a broad array of academic backgrounds engage in policy-related research related to health and health care, Scott Burris, Alexander Wagenaar, Jeffrey Swanson, Jennifer Ibrahim, Jennifer Wood, and Michelle Mello believe that insufficient attention has been paid to law as an area of research. In “Making the Case for Laws That Improve Health: A Framework for Public Health Law Research [PHLR],” they lay out the terrain of a field that has not been previously identified as such, defining PHLR as “the scientific study of the relation of law and legal practices to population health.”
This article is one of the first products of a new Robert Wood Johnson Foundation program to sponsor PHLR and expand the field. The emphasis is on research using empirical methods, which distinguishes PHLR from legal “scholarship.”
Public health law research can use the full spectrum of health services research methods in studies of factors that influence what laws are adopted, analyses of how laws affect particular public health topics, studies of the implementation of laws and regulations and of the effects of legal interventions, and studies of the mechanisms through which the law affects outcomes of interest. Burris and his colleagues also discuss the challenges facing the field, including the need for more methodological rigor, better identification of relevant data sources, improvements in making the research relevant to policymakers, and, of course, adequate research funding.
The legal theme continues in the next article in this issue, “The Evolution of Health Care Advance Planning Law and Policy,” by Charles Sabatino. His analysis of the history of legal approaches to ensuring that people’s wishes are respected in end-of-life care begins with state laws to facilitate the creation of documents (“living wills”) that specified how a person wanted to be treated under different circumstances. This “legal transactional approach,” however, had several problems, which Sabatino describes, including its lack of flexibility and its concentration on legal formalities. For a variety of reasons, the legal documents had little effect on patient care, and the field evolved toward what Sabatino calls a “communications approach,” which is much more iterative and flexible. With the emphasis on ongoing communication among the key parties, rather than on a document drawn up in advance, this approach has many advantages in Sabatino’s view. The laws in some states permit oral directives. Evidence concerning the extent to which the communications approach resulted in end-of-life care decisions that were more reflective of patients’ desires is quite limited.
The most recent step in the evolution of law in this area is toward an approach called “physician orders for life-sustaining treatment” (POLST), which is used with seriously chronically ill patients. POLST requires discussion between the treating health care practitioner and the patient or the patient’s authorized surrogate about treatment options at the end of life. The patient’s wishes are incorporated into the medical record in a way that is highly visible and that can be changed at any time. Sabatino describes POLST as an advance care planning tool rather than an advance directive.
Most legislation regarding end-of-life care has been at the state level. Nonetheless, Sabatino concludes his article with a discussion of implications for policy at the federal level, where the topic, as became evident in the health care reform debates of 2009, is particularly sensitive. The fact that 2.5 million Americans die every year is a measure of its importance, and people generally want to have their wishes respected regarding end-of-life care. The legal environment is important to making that happen.
The next article in this issue examines the growing interest in using research tools to prevent the hospitalization of high-risk patients. Geraint Lewis’s article “‘Impactibility Models’: Identifying the Subgroup of High-Risk Patients Most Amenable to Hospital-Avoidance Programs” is based on interviews conducted in 2008 with officials from some thirty organizations in the United States that are using predictive modeling to target certain services. Its three purposes are prioritizing patients with diseases that might respond to preventive care, excluding patients who would be unlikely to benefit from preventive services, and tailoring preventive services to individual patients. After describing the ways that predictive modeling is being used for these purposes, Lewis discusses its potential benefits for improving patient care as well as the danger that predictive modeling could be used in ways that increase disparities in health and health services.
There is great current interest in evidence-based decision making in all aspects of health policy. In “EBM, HTA, and CER: Clearing the Confusion,” Bryan Luce, Michael Drummond, Bengt Jönsson, Peter Neumann, J. Sanford Schwartz, Uwe Siebert, and Sean Sullivan argue that policy discussions are damaged by inconsistencies in how the central concepts of evidence-based medicine (EBM), health technology assessment (HTA), and comparative effectiveness research (CER) are used. The authors try to correct these inconsistencies by offering an organizing framework based on two sets of distinctions. The first is among evidence generation, the synthesis of evidence, and decision making based on evidence. The second is among questions of efficacy (Can it work?), effectiveness (Does it work in practice?), and value (Is it worth it?). The value question is then subdivided into value as seen from the perspective of the patient and from that of the collective (payers or society). The authors use the resulting nine-cell figure to show how the three related terms, EBM, HTA, and CER, overlap with one another in confusing ways in current usage and how they can be redefined in ways that minimize the overlap and, the authors hope, the confusion. They also use this figure to illustrate the relationship between kinds of evidence and decisions about efficacy, effectiveness, and value.
Bradford H. Gray
Editor, The Milbank Quarterly
Funtowicz, S.O., and J.R. Ravetz. 1993. Science of the Post-Normal Age. Futures 25:735–55.
Halfon, N., and M. Hochstein. 2002. Life Course Health Development: An Integrated Framework for Developing Health, Policy, and Research. Milbank Quarterly 80(3):433–79.
Author(s): Bradford H. Gray
Volume 88, Issue 2 (pages 145–148)
Published in 2010